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PKR Left knee patellofemoral arthroplasty

zdclimber

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I had patellofemoral arthroplasty done on my left knee with Arthrosurface Hemicap Wave Kahuna implant on the morning of 4/2. The surgeon also did arthroscopic lateral meniscus debridement and lateral retinacular lengthening.

First, a bit background about myself. I am a 52-year-old male, and am a runner/climber/skier/cyclist. Over the years, I ran several full marathons, with the latest being 2015 Boston marathon. I climbed a lot in PNW, summitted Rainier over a dozen times, and climbed Denali in 2017. I also ski 30-40 days a season, and bike regularly, including a couple of 1000+ miles bike tours.

In fall of 2017, I started to develop pain around my left kneecap. This forced me to stop running and climbing. I kept on skiing and biking. In spring of 2019, after a 60-day ski season, the condition of my left knee deteriorated quickly. While X-Ray still looked normal, MRI showed a small full-thickness cartilage defect under my kneecap. I then rested for 2 years, with walking, moderate biking, and knee related PT as the only regular exercises. I also had a PRP injection at the end of 2019.

All these effort did not really improve the condition of my knee. What finally made me decide to get surgery is my skiing experience early in December of 2020. After skipping the while ski season last season, I put on ski boots again, only to find that I felt quite a bit of pain on both my knees on every turn, left knee being worse than the right. I ended up only skiing for 2 hours that day and had pain walking up and down stairs the following 5-6 days. I went skiing again, the same thing repeated.

Over the last 3-4 years I did a lot of research on treatment of patella cartilage defect. After talking to 3 different orthopedic surgeons, I decided to go with patellofemoral arthroplasty with Arthrosurface Hemicap implant.

I did pre-op strengthening as suggested by some forum members. Interestingly, my symptom actually improved a bit after the month long pre-hab. I even had a slight hesitation about the surgery but convinced myself that surgery was still a better choice given my active lifestyle.
 

Celle

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Hello @zdclimber- and :welome:

Here are our recovery guidelines, to help you - lots of helpful articles.
Knee Recovery: The Guidelines

People are all different, as are the approaches to this recovery and rehab. The key is, “Find what works for YOU.“ Your doctor(s), physiotherapist(s) and BoneSmart are here to help, but YOU are the final judge as to the recovery approach you choose.

1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary.

2. Control discomfort:
rest
ice
take your pain meds by prescription schedule (not when pain starts!)​

3. Do what you want to do BUT
a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you​
b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

4. PT or exercise can be useful BUT take note of these

5. Try to follow this

6. Access to these pages on the website

The Recovery articles:
The importance of managing pain after a TKR and the pain chart
Swollen and stiff knee: what causes it?
Energy drain for TKRs
Elevation is the key
Ice to control pain and swelling
Heel slides and how to do them properly
Chart representation of TKR recovery
Healing: how long does it take?
Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

There are also some cautionary articles here
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds

We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.

While members may create as many threads as they like in the majority of BoneSmart’s forums, we ask that each member have only One Recovery Thread. This policy makes it easier to go back and review the member’s history before providing advice, so please post any updates or questions you have right here in this thread.
 
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zdclimber

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The surgery started shortly after 7:00am on 4/2. The first part is the diagnostic arthroscopy, to make sure I was indeed a good candidate for the PFJR. The surgeon said my kneecap had a large area of cartilage defect and there were some tears in my lateral meniscus. The rest of my left knee was in pristine condition. He then fixed my meniscus arthroscopically. I dozed off after that point, and when I woke up it was 9:30am, the surgery was just over. The surgeon told me that the surgery went extremely well. Later from the sheet he gave me, apparently he also did lateral retinacular lengthening.

A couple of things worth mentioning while I was in recovery room.

One is that I developed nausea early in the afternoon, and had to throw up a few times. Even after taking Zofran, it did not improve much. I threw up repeatedly during the ride back home that evening.

The second is that I had trouble urinating, despite having a full bladder. At some point the nurse said she had to use a catheter and I had to beg her to give me more time. Eventually, I did it on my own.

I was given instruction on medication and was discharged right after 5:00pm.

The first night was uneventful. Other than feeling nauseous, everything else was fine. No pain at all.
 
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zdclimber

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Update at the end of day 4 -

Pain: no pain at all at rest, but pain gets progressively worse when I move my legs. In particular, I could easy do straight leg raise on day 1 but now it is too painful to do it.

ROM: 0-90 on day 1, now regress to 0-60. Max flex degree is when I start to feel some pain. If I push it, I may be able to get a few more degree.

Nausea: Gone after day 2.

Dizziness: low blood pressure (95/55, vs my usual BP of 110s/70s) and low heart rate (low 50s vs my usual low 60s) starting from day 1 but gets better every day.

Swelling: Quite a bit. I feel that my narrow ROM is mostly due to the swelling at this point.

Constipation: started from day 1, not improving.

Pain medication: I have been taking one 5mg tablet of Oxycodone every 6 hours. Given that I did not experience much pain, I will reduce it to 2.5mg every 6 hours for the next 2 days. If there is no increase in pain level, I will stop taking Oxy. I am also taking Tylenol totaling 1300mg every day. I will keep the Tylenol dosage as I reduce and drop Oxy.
 

Jockette

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Even though you had a partial, it was still major surgery and your surgeon did major carpentry work inside your knee. I also have a Patellofemoral, and it was not the easy, quick recovery I was led to believe!

It is normal for swelling to increase in the early days, which like you said, will reduce ROM. Don‘t worry about it, the ROM will return and improve, but it takes time.

If an exercise hurts, don’t do it, it means your knee isn’t ready for it. Try it again another day, or better yet, another week. Don’t push yourself into pain, that doesn’t improve anything, it will create more pain and swelling, which is counterproductive.

Regaining our ROM is more about Time than repetitions of a list of exercises.

Time to recover.
Time for pain and swelling to settle.
Time to heal.

Our range of motion is right there all
along just waiting for that to happen so it can show itself.

In the general run of things, it doesn't need to be fought for, worked hard for or worried about. It will happen. Normal activity is the key to success.
 

Celle

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In particular, I could easy do straight leg raise on day 1 but now it is too painful to do it.
So give it a rest for a while. You know you can do it, but you don't need to do it every day. As your pain decreases, you will be able to do it again.

ROM: 0-90 on day 1, now regress to 0-60. Max flex degree is when I start to feel some pain. If I push it, I may be able to get a few more degree.
Your flexion has decreased because your swelling has increased. That's normal. Don't push your knee.

There's no need to rush to get ROM (Range of Motion) because it can continue to improve for a year, or even much longer, after a knee replacement. There isn't any deadline you have to meet:
Myth busting: the "window of opportunity" in TKR
Swelling: Quite a bit. I feel that my narrow ROM is mostly due to the swelling at this point.
Correct. Your ROM will increase spontaneously as your swelling decreases.

Constipation: started from day 1, not improving.
The narcotic medications cause your gut to slow down, making you constipated.
This article may help:
Constipation and stool softeners
In addition, you may need to take an aperient.
 
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zdclimber

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Thanks Jockette and Celle for your responses and the advises. This is pretty much exactly what I have been following.

Brief update at 1 week post-op -

The biggest change is medication. I was off Oxycodone on day 5 and gradually reduced Tylenol doses over the last few days. There was not much change in pain level, still no pain at rest and either no or some minor pain when moving around. Constipation condition improved after stopping taking Oxycodone and is completely gone today.

ROM remains at 0-60. I am not working on it, other than just checking it daily to see where it is.

Leg raise is still too painful to do. Again, I am not working on it, just a daily check if it's improving.

Sleeping is really good. Solid 8+ hours of sleep almost every night.

The biggest problem is swelling. It's quite bad despite 23+ hours everyday to have my leg elevated and in a compression sock. I also ice it on/off throughout the day and during sleep (with a 30min on/off timer) as well. It seems there is not much else I can do. This thing just takes time and needs a lot of patience I guess.
 

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This thing just takes time and needs a lot of patience I guess.
Unfortunately that is all too correct @zdclimber. :shrug: There is no way to rush healing from major surgery like this. While patience isn't easy, that and lots of ice are your best path to healing.
 

Jockette

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You’re doing all the right things. Yes, this recovery takes time. Your leg has been through a lot, thus the swelling. Hang in there!
 

Celle

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I also ice it on/off throughout the day and during sleep (with a 30min on/off timer) as well. It seems there is not much else I can do. This thing just takes time and needs a lot of patience I guess.
You need to ice for 45 to 60 minutes each time. 30 minutes isn't long enough.

As long as you protect your skin well, with sufficient material between your skin and the icing medium, it doesn't do any harm if you ice continuously. The protocol is different from icing after an injury.

This is how Jamie explained it:
"After surgery ice is frequently used as a means to minimize pain and swelling because of the surgical trauma. It's not the same use as you might do after an injury. Following injury, it is common practice to tell patients to ice no longer than 20-25 minutes several times a day. But with a surgical incision, it is perfectly fine to ice your wound as much as is comfortable for you providing that you do not allow your skin to chill to the point of damage. This is why we recommend that people use a towel between the ice source and their skin or clothing. It's also why the ice machines like Game Ready or DonJoy have pads that don't get quite as cold as you can do with an actual ice pack. Icing is an excellent means to control pain following surgery and each individual needs to find out what schedule works best for them."

And yes, this recovery takes a long time and it does require a lot of patience.
 

sistersinhim

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I iced the whole time I was sitting or laying down for at least a month. This really helped with reducing my pain and swelling. I used the Lounge Doctor for elevation, which I was quite happy with.
Elevating Dos and Don'ts
 
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zdclimber

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Thanks all for your advice and encouragement. Now it's end of week 2 post surgery, and there is significant progress in my recovery during the last week.

I still don't have any pain, except when attempting some exercises that my OS prescribed. I still have good, uninterrupted sleep almost every night. Swelling is reduced somewhat, and unsurprisingly, ROM is improved accordingly, now at 0 - 80/85. This unfortunately means I am still quite a ways from being able to ride my bike.

Moving around gets much easier. I don't need my crutches anymore, except for going down stairs (going up is fine). I also started walking outside of my house, using hiking poles for safety. I am now doing 1/4 mile (400m) twice a day. My operated leg/knee is not tired at all after the walk. I feel I could have gone much longer, but I also know that overdoing it at this stage is definitely unwise.

I am able to do straight leg raise now, but not without pain. So I only do a few reps before the pain intensifies.

I will have my first PT session next Monday. I mainly want to see if they can help me reduce my swelling so that I can have good enough ROM to ride my bike sooner. I will make it clear that I don't want to do (or have them do to me) anything that would inflict pain. My past experience with PT or injury recovery was "less is more" and I want to stick with it.
 

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I will have my first PT session next Monday. I mainly want to see if they can help me reduce my swelling so that I can have good enough ROM to ride my bike sooner.
@zdclimber , Even though you had a patellofemoral PKR, your knee still had major surgery. It needs time and gentle treatment, so it can heal. Complete recovery of all your tissues can take a full year, although you will be able to do most things long before that.

Although it's a nuisance for you, the swelling that prevents your knee from bending far enough for you to ride your bike is doing a good job of protecting your wounded knee from being over-exerted before it has healed enough.

Your knee is healing on its own schedule and trying to speed that up could result in a knee that becomes irritated and inflamed, which will slow down your recovery.

Trying to do too much, too soon, is counter-productive.

What's really important is that your knee should heal properly, not that you can ride your bike a bit sooner.
Please try to be patient, and give your knee the time it needs.
 
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zdclimber

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Although it's a nuisance for you, the swelling that prevents your knee from bending far enough for you to ride your bike is doing a good job of protecting your wounded knee from being over-exerted before it has healed enough.
That is an interesting perspective that I never thought of. I agree that over-exerting during rehab in an attempt to speed up recovery is counter-productive. But on the other hand, doing the right exercise with the right intensity for my knee will likely help with the recovery. In my case, the main issue is swelling. I'd like to see if the physical therapist has better ideas than simply icing/elevating/compressing. Of course, I will refuse to do anything will over-work my knee.
 
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Week 3 update -

Slow progress this week. I am now off any meds completely. (Still taking supplements like multi-Vitamin, fish oil, etc.) No perceived increase in pain level, which is pretty much non-existent at rest. All PT exercises are done within pain-free range.

There is only limited increase in my ROM, now at about 90 degree, increased from 80/85 a week ago. This gets me a bit frustrated but not yet overly concerned at this point. When I flex my knee, I start to feel tightness/resistance at about 60 degree, from there to 90 degree, the tightness/resistance increases. I feel discomfort at close to 90 degree but no pain. Every step I take during walk is like a gentle stretch for my knee as it bends slightly over 60 degree, which I assume is a good thing. My walking distance is about 3/4 mile (1.2km) once a day.

One day early in the week when I sat down, I completely forget about my surgical knee and sat down normally with both my feet very close the chair, I immediately felt excruciating pain when the knees bent well over 90 degree. The pain last only a few seconds fortunately but it may have set my recovery back for a few days.
 

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For 3 weeks post op, you are doing very well. Everything you wrote is very normal for this recovery.

There is only limited increase in my ROM, now at about 90 degree, increased from 80/85 a week ago. This gets me a bit frustrated but not yet overly concerned at this point.
Please don’t worry about your ROM, it will return. No need to worry, no need to try hard for it. That gentle stretch you feel when walking is the best, gentle way to regain your ROM.

The pain last only a few seconds fortunately but it may have set my recovery back for a few days.
Maybe a slight setback, if you want to call it that, but these things happen and it’s hard to totally avoid them. It’ll be ok.
 

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One day early in the week when I sat down, I completely forget about my surgical knee and sat down normally with both my feet very close the chair, I immediately felt excruciating pain when the knees bent well over 90 degree.
That's what we call a manipulation without anesthesia. We have all done it to some extent. You know your knee will bend that much, just that it was too much at this early stage of recovery.
 
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zdclimber

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That's what we call a manipulation without anesthesia. We have all done it to some extent. You know your knee will bend that much, just that it was too much at this early stage of recovery.
Too bad I paid the price but did not benefit from this manipulation. My knee was stiffer and ROM decreased a little afterwards, maybe for a day or so.
 

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Too bad I paid the price but did not benefit from this manipulation. My knee was stiffer and ROM decreased a little afterwards, maybe for a day or so.
Your knee was stiffer because the extra bending angered it and it reacted with swelling. That swelling adds to the stiff feeling. I'm glad it starting to get better.
 
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Week 4 update -

Another week of slow and steady progress. ROM increased from around 90 degree to 105/110. I am able to make a few revolutions on my recumbent stationary bike but it comes with a bit of pain so I am not doing it much. I can go upstairs normally now, but still need to place my surgical leg first when going down stairs. My daily walking distance is at 1.5 miles (2.4km).

Biggest challenges now are 1. swelling and 2. pain in the quad tendon when loaded.

I was back to work (work from home) from week 2, but the first 2 weeks I was mostly sitting in bed with my surgical leg elevated and using a laptop computer to work. Starting from this week, I was back to my desk and I noticed that my leg was swelling more. I know I need to take frequent breaks to ice and/or elevate my knee but always forget when work takes over.

I have no problem with straight leg raise now, but can barely do leg extension. The quad tendon is quite painful after just 1 or 2 reps.

Despite the challenges, I am pretty happy how my recovery goes.
 

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